Predictors Of Treatment Adherence Research Articles

Individual-Level Social Determinants of Health (SDOH) Measures and Treatment Complications in Acute Leukemia

Background Population studies demonstrate widening survival disparities in AML survival. In our previous analysis, census tract-based measures of socioeconomic status accounted for most of the AML death disparity for non-Hispanic Black (NHB) and Hispanic patients (pts) suggesting that patients' social and physical environments contribute to poor AML endpoints (Abraham et al. Blood 2022). However, these data are retrospective and only provide neighborhood-level information. We prospectively collected individual level data on SDOH and linked this to treatment delivery and complications. Methods Patients were prospectively enrolled from two institutions: a comprehensive cancer center and a minority-serving cancer center for a planned 2 year follow-up. A mixed-methods approach utilized validated questionnaires and semi-structured interviews administered to patients 30-90 days from diagnosis and data was collected on adherence, falls, infections, ER visits, hospitalizations, and ICU admission. Quantitative measures included patient neighborhood and environmental living conditions (AHC HRSN), health literacy (CHLT-6), financial toxicity (COST-FACIT), medication affordability/adherence (ARMS), and mental health (PHQ-4). Quantitative data was supplemented with qualitative data from semi-structured interviews from a subset of patients. We used linear regression to estimate statistical differences in means between groups. Results We report results from 52 patients, predominantly with AML and high-risk MDS followed for up to 6 months. Baseline characteristics are summarized in Table 1. Median age was 62 years. 38% were non-Hispanic White (NHW), 25% NHB, and 23% Hispanic and lived in socioeconomically diverse census tracts. Half the cohort had a high school education or less. 40% had an annual income level < $25,000. 40% pts had a Charlson comorbidity index (CCI) ≥ 5. On the AHC HRSN tool, housing and food insecurity were reported in 10% and 15%, respectively, 40% reported difficulty paying for basic needs and 22% loneliness/isolation. In terms of care delivery, pts aged ≥ 65 years were more likely to miss clinic visits (p=0.026) and chemotherapy treatments (p=0.005). Non-white (p=0.13) pts and those on public insurance (p=0.04) were also more likely to miss clinic visits. Education level, income, and marital status were not associated with missed visits/treatments. Assessing treatment complications 60% of ER visits occurred with annual household incomes under $50,000 (p=0.048). Education and insurance were also linked to treatment morbidity, with 75% of ICU admissions having a high school education or less (p=0.09) and 83% having Medicare or Medicaid (p=0.087). Rates of mechanical ventilation mirrored these findings. Education was associated with lower rates of discharge to SNF or SAR, 72% of college or higher-educated pts were discharged home (p=0.035). Fall rates and infectious complications did not differ based on SDOH. Interestingly age and CCI did not distinguish between any of these treatment complications. Validated patient reported measures of social vulnerability were next examined as predictors of treatment adherence and complications (Table 2). The mean COSTFACIT was 9.8 lower (95% CI -17.6 to -1.93) in those with ER visits than those without ER visits (p=0.061). The mean CHLT-6 score was 0.96 lower (95% CI -1.8 to -0.09) in pts admitted to the ICU (p = 0.03). The PHQ-4 score did not differ based on any complication. Discussion This study represents the first attempt to prospectively link patient reported SDOH to treatment delivery and early complications in leukemia and provides valuable insights into targetable barriers to overcome disparities. Age was the most significant risk factor for missed clinic visits and chemotherapy doses. Older pts may benefit from navigators, caregiver engagement, tailored education given increased reliance on complex outpatient regimens. Treatment complications were strongly associated with SDOH, including education and household income. These findings suggest that pre-treatment ‘fitness’ assessments and greater home-based visits during treatment may mitigate ER visits and life-threatening complications. Importantly, quantitative SDOH measures such as COST-FACIT and CHLT-6 can prospectively identify patients at risk of early complications and become an important tool to triage these resources.

Adherence to biological therapies in patients with rheumatoid arthritis: a retrospective cohort study.

The advent of biologic disease-modifying antirheumatic drugs has dramatically changed the comprehensions of treatment and long-term prognosis in patients with rheumatoid arthritis. The potent therapeutic results can only be achieved if the patients adhere to prescribed medications. The objective of this study was to estimate the impact of age, gender, duration of the disease, concomitant Methotrexate therapy, prior exposure to biologic agents, disease activity, functional capacity, and health-related quality of life on adherence to biologic treatment among Bulgarian population with rheumatoid arthritis. This was a retrospective observational cohort study that included 179 patients. At the baseline visit and subsequent follow-up assessments at 6, 12, 24 and 36months, patients were interviewed by a physician and underwent physical examinations. We monitored the changes in disease activity, functional capacity and health-related quality of life on each time point. Univariate and multivariate binary logistic regression was used to determine the prognostic value of possible predictors of treatment adherence. Our findings showed that only DAS28 score [odd ratio (OR) = 1.174; 95% CI 1.74-2.362] and HAQ score (OR 2.803; 95% CI 1.428-5.503) remained significant for the treatment adherence throughout the study period. The adherence to the biologic disease-modifying anti-rheumatic drugs among Bulgarian patients with rheumatoid arthritis is suboptimal. A multifaceted and comprehensive knowledge of the influencing factors can be useful for the development of different strategies that can improve treatment adherence.

The predictive role of intimate partner violence in treatment adherence among women with chronic illness: A cross-sectional study.

This study was an attempt to shed light on the predictive role of intimate partner violence in adhering to treatment regimens in women with chronic illnesses. In a descriptive-analytical study, 400women with chronic illnesses in Bushehr were selected through convenience sampling. The data were collected by distributing a demographic information form and two questionnaires, including the intimate partner violence (IPV) questionnaire and the treatment adherence scale. According to the results, the 40 to 59 years age group (P = 0.046, β = 0.104), the 60 to 79 years age group (P = 0.019, β = 0.122), and the group receiving education about chronic illness (P = 0.031, β = 0.106) showed a direct relationship with treatment adherence, while IPV (P < 0.001, β = 0.284) had a significant inverse relationship with treatment adherence. The results of the study showed that predictors of treatment adherence are IPV in women aged 40 and older with chronic illnesses, and receiving education about chronic illnesses. It is necessary for healthcare providers to consider barriers such as intimate partner violence when providing education in order to increase treatment adherence. To avoid nonadherence, managers and health planners should implement policies to increase the level of awareness of healthcare staff on how to manage care of women with chronic illnesses who are abused by an intimate partner and refer them to counselors and family helpers.

Predictors of Effectiveness and Adherence in a Multimodal Obesity Treatment Program for Children and Adolescents in Routine Care.

Multimodal obesity treatments for children and adolescents generally showed only small to modest treatment effects and high dropout rates. Potential variations by patients' clinical and sociodemographic factors remain, however, largely unclear. For this reason, our study analyzed psychological, physical, and sociodemographic predictors of treatment success and adherence in a multimodal obesity treatment over 12 months. The intent-to-treat sample included n = 361 children and adolescents (ages 3-17 years), of which n = 214 or 59.28% of patients completed treatment. A younger age and, in the sensitivity analysis, additionally a greater eating disorder psychopathology and treatment initiation before COVID-19 pandemic predicted greater BMI-SDS reductions (Body Mass Index-Standard Deviation Score). In contrast, predictors of treatment adherence were not found. The results underline the importance of early treatment of juvenile obesity. Additionally, eating disorder psychopathology includes restrained eating, which implies the ability to self-regulate eating behavior and therefore may have a positive effect on the treatment goal of controlled food intake. Challenges from altered treatment procedures due to the COVID-19 pandemic nonetheless remain.

Social Determinants: Reinforcing and Enabling Factors as Predictors of Treatment-Adherence in Community-Based Drug Resistant Tuberculosis Patients in South-West, Nigeria

Social Determinants: Reinforcing and Enabling Factors as Predictors of Treatment-Adherence in Community-Based Drug Resistant Tuberculosis Patients in South-West, Nigeria

Predictors of treatment adherence in patients with chronic disease using the Multidimensional Adherence Model: unique considerations for patients with haemophilia

Abstract Introduction Adherence to treatment recommendations in patients with chronic disease is complex and is influenced by numerous factors. Haemophilia is a chronic disease with reported levels of adherence ranging from 17–82%. Aim Based on the theoretical foundation of the World Health Organization Multidimensional Adherence Model, the objective of this study was to identify the best combination of the variables infusion frequency, annualised bleed rate, age, distance to haemophilia treatment centre (HTC) and Haemophilia Joint Health Score (HJHS), to predict adherence to treatment recommendations in patients with haemophilia A and B on home infusion prophylaxis in Canada. Methods A one-year retrospective cohort study investigated adherence to treatment recommendations using two measures: 1) subjective report via home infusion diaries, and 2) objective report of inventory ordered from Canadian Blood Services. Stepwise regression was performed for both measures. Results Eighty-seven patients with haemophilia A and B, median age 21 years, were included. Adherence for both measures was 81% and 93% respectively. The sample consisted largely of patients performing an infusion frequency of every other day (34%). Median scores on the HJHS was 10.5; annualised bleed rate was two. Distance to the HTC was 51km. Analysis of the objective measure weakly supported greater infusion frequency as a treatment-related factor for the prediction of lower adherence, however the strength of this relationship was not clinically relevant (R2=0.048). For the subjective measure, none of the explanatory variables were significant. Conclusion Adherence is a multifaceted construct. Despite the use of theory, most of the variance in adherence to treatment recommendations in this sample of patients with haemophilia remains unknown. Further research on other potential predictors of adherence, and possible variables and relationships within factors of the MAM is required.

Adolescent-Sleep-Intervention Research: Current State and Future Directions

Emerging evidence suggests that cognitive-behavioral interventions should be considered as a first-line treatment for adolescent sleep problems and can also address associated mental health concerns. This article’s aim is to prioritize future directions for this research. Studies are needed that (a) leverage innovative technology, which may allow for a more personalized-medicine approach to care; (b) use alternative research designs, such as treatment-optimization strategies; (c) evaluate mechanisms of therapeutic improvements, including mediators and moderators of change, predictors of treatment adherence, dose–response relationships, and specificity of effects of different treatment components; (d) “scale up” the interventions so that a large proportion of adolescents can access them; and (e) develop flexible approaches to delivery (e.g., online platforms) and stepped-care guidelines. National and international standards of secondary school start times of 8:30 a.m. or later are also needed. The field is now mature enough to take these next steps, which will enhance the effectiveness and public health impact of these interventions.

Nasal function and CPAP compliance

ObjectiveContinuous positive airway pressure (CPAP) is the mainstay therapy for patients with obstructive sleep apnea (OSA) however compliance with CPAP is variable. Nasal ailments, such as nasal congestion are frequently mentioned as a cause for CPAP non-compliance, and potentially could be addressed prior to CPAP initiation, however, no specific criteria or recommendations for the evaluation and management of these patients exist. The aim of this retrospective study is to evaluate the effects of nasal anatomic features and disease on adherence to CPAP therapy for patients with OSA and determine the indications for pre-CPAP nasal treatment by using data obtained at clinical examination. MethodsIn total, 711 adult patients with initial diagnosis of OSA and an apnea–hypopnea index of ≥20 who were amenable to CPAP were included. We analyzed nasal parameters, past history of nasal disease, subjective symptoms, and disease severity in addition to whether CPAP therapy had been initiated, rate of CPAP therapy use (initial and 1year), treatment continuation rate at 2 months and 1year, and nasal treatments for all patients. ResultsCPAP therapy was initiated in 543 of 711 patients. Nasal resistance was significantly higher in patients who discontinued therapy soon after CPAP initiation. Nasal disease and nasal parameters were not found to be predictors of treatment adherence at 1year.Allergic rhinitis, moderate to severe nasal congestion at bedtime, slight or extensive sinus opacification, and a high nasal septum deviation score were found to be independent predictors of nasal treatment, while strong awareness of nasal congestion, a past history of sinusitis, and a total nasal resistance (supine position) of ≥0.35Pa/cm3/s were independent predictors of surgical treatment. ConclusionLong-term CPAP therapy adherence in patients with OSA can be predicted from initial CPAP adherence. Nasal disease and nasal parameters are important factors for early CPAP therapy discontinuation and should be adequately treated before therapy initiation to ensure long-term adherence. Indications for pre-CPAP nasal treatment and nasal surgery for patients with OSA can be predicted from the data obtained at the first examination, and these patients should be treated differently from those without OSA.

Predictive factors of treatment adherence in cancer outpatients.

Identify which variables are predictors of treatment adherence in cancer patients. Two hundred twenty cancer outpatients were evaluated by the following instruments: questionnaire on sociodemographic and clinical data, NEO-FFI Personality Inventory Revised (NEO-FFI-R), Multidimensional Health Locus of Control (MHLC) scale, Hospital Anxiety and Depression Scale (HADS), patient's knowledge about cancer disease questionnaire, and Adherence Determinants Questionnaire (ADQ). A logistic regression analysis was applied to verify the predictive power of the variables, and network analyses were conducted through the qgraph package. The sample was composed of 138 (62.7%) women and 82 (37.3%) men. The mean age of participants was 54.66 (SD=13.30), and the education level mean was 8.32 (DP=3.76) years of study. Powerful others locus of control (LOC) and the personality factors conscientiousness and agreeableness are presented as predictors of high treatment adherence. The variable family cancer history, on the other hand, was a predictor of lower adherence levels. The powerful others LOC may be connected with more trust and dependence in the health team, leading to better adherence. Specific characteristics of personality factors can help individuals to cooperate with their caregivers and to follow medical orders. The evaluated factors are interrelated and should be taken into account by health professionals when developing interventions to modify health-related behaviors and treatment adherence.

Predictors of treatment adherence and HIV viral load among youths transitioning from pediatric to adult HIV outpatient care in São Paulo, Brazil

Predictors of treatment adherence and HIV viral load among youths transitioning from pediatric to adult HIV outpatient care in São Paulo, Brazil

Comparison and predictors of treatment adherence and remission among patients with schizophrenia treated with paliperidone palmitate or atypical oral antipsychotics in community behavioral health organizations

BackgroundNonadherence to antipsychotic treatment increases the likelihood of relapse and progressive symptomatology in patients with schizophrenia. Atypical long-acting injectables, including paliperidone palmitate (PP), may increase adherence and improve symptoms. This study compared and assessed predictors of treatment patterns and symptom remission among schizophrenia patients treated with PP versus atypical oral antipsychotic therapy (OAT) in community behavioral health organizations (CBHOs).MethodsThis retrospective cohort analysis evaluated 763 patients with schizophrenia and new (PP-N; N = 174) or continuing (PP-C; N = 308) users of PP, or new users of OAT (N = 281) at enrollment in the REACH-OUT study (2010–2013). Treatment outcomes assessed at 1 year were discontinuation, and adherence, measured by proportion of days covered (PDC) or medication possession ratio (MPR). Remission status was assessed using the Structured Clinical Interview for Symptoms of Remission (SCI-SR). A machine learning platform, Reverse Engineering and Forward Simulation (REFS™), was used to identify predictors of study outcomes. Multivariate Cox and generalized linear regressions estimated the adjusted hazard ratios (HRs) or odds ratios (ORs) with 95% confidence intervals.ResultsAmong PP-N users, 27% discontinued their initial treatment regimen versus 51% (p < 0.001) of OAT users. PP-N (vs OAT; HR = 0.49 [0.31–0.76]) users and males (HR = 0.65 [0.46–0.92]) had significantly lower rates of discontinuation. Relative to OAT, PP-N had a 36% [31%–42%] higher MPR and a 10-fold increased achievement of PDC ≥80% (OR = 10.46 [5.72–19.76]). PP users were significantly more likely to achieve remission in follow-up (PP-N vs OAT: OR = 2.65 [1.39–5.05]; PP-C vs OAT: OR = 1.83 [1.03–3.25]).ConclusionsRelative to OAT, PP was associated with improved adherence, less frequent treatment discontinuation, and improved symptom remission in this CBHO study population.

Improving Treatment Adherence in Type 2 Diabetes: What Kind of Intervention Could be Offered?

Treatment adherence is a key factor to achieve stable glucose level in type 2 diabetes. Treatment adherence is defined as changes in lifestyle associated with self-care behaviors, like diet and exercise. The purpose of the study was to identify potentially modifiable factors based on patient illness perception associated with treatment adherence among people with type 2 diabetes and to develop intervention based on the result to increase the adherence. 152 respondents (males 37,5%, females 62,5%) were recruited from several public health institutions in Jakarta. The mean age of the study group was 57,9 years, and the mean duration of diabetes was 6,9 years. Measurements used were Self-Care Inventory Revised (SCI-R), Brief Illness Perception Questionnaire (B-IPQ), Self-Efficacy for Diabetes, and Social Support Questionnaire 6 (SSQ-6). Significant predictors of treatment adherence were self-efficacy, subscale treatment control and concern of illness perception. Based on that result, we developed 4 -session group therapy focusing on illness perception aspect, and also developed the intervention module and booklet for respondents.

Low Treatment Adherence in Pubertal Children Treated with Thyroxin or Growth Hormone

Background: Treatment outcome depends largely on treatment adherence (TA). However, studies analyzing TA in chronic endocrine diseases are scarce and controversial in childhood. Patients and Methods: We studied TA in 103 children treated subcutaneously with growth hormone (GH) and 97 children treated orally with thyroxin. TA was calculated based on the prescription refill rates. The number of GH injections was recorded by an autoinjector device in 23 children treated with GH. Results: The correlation between recorded TA and calculated TA based on prescription refill rates was very good (p < 0.001, r = 0.83). TA was lower (p < 0.01) in pubertal children compared to prepubertal children and in children self-administering their medication compared to those whose drug was administered by their parents, both in GH- and thyroxin-treated children. Overall, 67% of the pubertal children treated with GH and 58% of the pubertal children treated with thyroxin missed at least 1 dose per week. TA was higher (p < 0.001) in children with thyroxin treatment compared to children treated with recombinant human GH (8 vs. 26% missed >3 doses/week). Discussion: Puberty and self-administration of drugs were negative predictors of TA. Therefore, in puberty, prevention and treatment efforts should be undertaken to improve TA, especially when adolescents administer their drugs themselves.

Association between diabetes treatment adherence and parent-child agreement regarding treatment responsibilities.

When primary responsibility for Type 1 diabetes (DM1) treatment adherence transfers from parents to adolescents, glycemic control often suffers. Low rates of treatment adherence during this transition are possibly attributable to decreased parental involvement, disagreements between parents and children regarding treatment responsibilities, and increased family conflict. The current investigation assessed the relationships between each of these variables and glycemic control among youth diagnosed with DM1. Parent and child report questionnaires were completed by 64 parent-child dyads (ages 8-18) with a child diagnosed with DM1. HbA1c readings served as measures of glycemic control. Parental involvement in their children's treatment was reported to decline with age, however absolute levels of parent involvement were not significantly correlated with youth HbA1c levels. Parent-child agreement regarding treatment responsibility and reports of diabetes-related conflict were significant predictors of glycemic control. Results support previous findings implicating parent-child agreement regarding treatment responsibilities and family conflict as predictors of treatment adherence among youth with DM1. The current study found this relationship to be significant for a larger population of children for which past research has failed to find such an effect. Taken together, these findings suggest further research is warranted to identify effective methods for transferring treatment responsibilities from parents to children.

801 – Comprehension and companionship in the emergency department as predictors of treatment adherence: a prospective study

Introduction Lack of adherence to recommended treatment poses major clinical and economic challenges for psychiatry, and requires further study. Objectives and aims We aimed to prospectively investigate the association between the level of understanding of psychiatric emergency department (ED) discharge recommendations and presence of a companion with short term treatment adherence. Methods Sixty subjects were evaluated twice: upon ED discharge and a month later. Instruments included a structured questionnaire based on the MacArthur Competence Assessment Tool for Treatment, MMSE, and corroboration of data with the computerized hospital medical file. Results There was a significant association between patient understanding and adherence with medication instructions (p 2 (1)=7.0, p Conclusions Ensuring patients' understanding of treatment recommendations and encouraging the company of patients are achievable, practical strategies that may improve adherence and thereby promote better outcomes.

Comprehension and companionship in the emergency department as predictors of treatment adherence

Lack of adherence to recommended treatment poses major clinical and economic challenges for psychiatry, and requires further examination. In this pilot study, we aimed to prospectively investigate the association between the level of understanding of psychiatric emergency department (ED) discharge recommendations and the presence of a companion with short-term treatment adherence. Sixty subjects were evaluated twice: upon ED discharge and a month later. Instruments included a structured questionnaire based on the MacArthur Competence Assessment Tool for Treatment, Mini Mental State Examination, and corroboration of data with the computerized hospital medical file. In order to control for the possibility that evaluation of the understanding of recommendations might positively influence adherence, the 60 subjects were randomly assigned into 50 who were interviewed with the full survey tool and 10 who were not asked questions about their understanding of treatment and/or follow-up recommendations. Understanding of discharge recommendations and the presence of a companion enhanced adherence. This preliminary study suggests that ensuring patients' understanding of treatment recommendations and encouraging the company of patients are achievable, practical strategies that may improve adherence and thereby promote better outcomes.

Outcome predictors in guided and unguided self-help for social anxiety disorder

Internet-based self-help with therapist guidance has shown promise as an effective treatment and may increase access to evidence-based psychological treatment for social anxiety disorder (SAD). Although unguided self-help has been suggested primarily as a population-based preventive intervention, some studies indicate that patients with SAD may profit from unguided self-help. Gaining knowledge about predictors of outcome in guided and unguided self-help for SAD is important to ensure that these interventions can be offered to those who are most likely to respond. Utilizing a sample of 245 patients who received either guided or unguided self-help for SAD, the present study examined pre-treatment symptoms and program factors as predictors of treatment adherence and outcome. The results were in line with previous findings from the face-to-face treatment literature: namely, the intensity of baseline SAD symptoms, but not depressive symptoms, predicted treatment outcomes in both unguided and guided self-help groups. Outcomes were unrelated to whether a participant has generalized versus specific SAD. Furthermore, for the unguided self-help group, higher credibility ratings of the treatment program were associated with increased treatment adherence. The findings suggest that guided and unguided self-help may increase access to SAD treatment in a population that is more heterogeneous than previously assumed.

Communication and culture: Predictors of treatment adherence among Mexican immigrant patients

This study examined communication and culture in clinicians' interactions with Mexican immigrants in Texas. Specifically, we explore the unique interplay among levels of acculturation, beliefs about culturally-based medical practices, perceptions of medical encounters, and the likelihood of adherence to medical therapy recommendations from US providers. Results suggest that: (a) acculturation predicts perceptions of out-group membership in the patient-provider interaction; (b) beliefs about complementary and alternative medicine are negatively related to medical adherence; (c) quality of care mediates the relationship between physician accommodation and medical adherence; and (d) there exists a complex relationship between out-group perceptions and adherence.

Predictors of treatment adherence in young children with type 1 diabetes

This paper reports a study to investigate whether diabetes-specific, demographic and psychosocial variables predict adherence in young children with type 1 diabetes. Paediatric diabetes rates are increasing worldwide; however, young children are neglected in treatment adherence research, despite the importance of adherence for health. Greater understanding of adherence in this group could enhance nurses' ability to provide care tailored to families' needs. A cross-sectional study was carried out between 2001 and 2003 with 65 children aged 2-8 years and their mothers in Britain. Mothers were interviewed about children's diabetes care, nutritional analyses were conducted and mothers completed assessments of diabetes knowledge, parenting stress, family functioning and child psychological adjustment. Demographic and medical information was collected from patient records. Consistent with older populations, blood glucose monitoring and dietary regimens showed greater adherence variability than injection frequency and injection time consistency. Better maternal diabetes knowledge correlated with less injection time variability, more frequent blood glucose monitoring, lower percentage energy intake from extrinsic sugars, lower glycosylated haemoglobin levels and fewer relationship difficulties. Longer diabetes duration, greater injection time variability and higher percentage energy intake from extrinsic sugars predicted less frequent blood glucose monitoring. More relationship difficulties and less frequent blood glucose monitoring predicted higher percentage energy intake from extrinsic sugars. Nurses can facilitate treatment adherence through provision of educational, practical and socio-emotional support. Nursing interventions should target blood glucose monitoring and dietary regimens in particular, and nurses should be sensitive to the various caretaking challenges presented to parents by different components of the diabetes regimen.

Family Structure and Mothers’ Caregiving of Children With Cystic Fibrosis

The purpose of this investigation is to examine differences in the experiences of mothers of children with cystic fibrosis who are in diverse family structures (first-marriage families, stepfamily households, single-parent households). In particular, mothers' perceptions of children's health, adherence to prescribed treatments, and help received from others were compared and predictors of treatment adherence were examined. Children's health and adherence to treatment regimens were not related to family structure. Mothers had the major responsibility for seeing that cystic fibrosis treatments were followed, regardless of family structure. Single mothers received less help than married and repartnered mothers. Married fathers helped with treatments more than nonresidential divorced fathers and stepfathers. Implications for nursing practice and suggestions for future research are offered.